NUTRITIONAL EDUCATION ENTERVENTIONAL STUDY

ON MANAGEMENT OF POLYCYSTIC OVARIAN DISEASE

PROJECT REPORT SUBMITTED TO

Indira Gandhi National Open University for

the partial fulfillment of degree of Master of

Science in Dieteties and Food Service

Management.

Submitted by:-

SYEDA NOOMA QARNEEN

Enrolment No.: 195568820

Regional Centre : Hyderabad (01)

Study centre: St.Ann's Women's College01662

Under the Supervision of

ASMA SAJID RD

Discipline of Food and Nutrition School of

Continuing Education (SOCE)

Indira Gandhi National Open University (IGNOU)

Maidan garhi, New Delhi- 110068

 DECLARATION
I declare that the presented thesis represents largely my own ideas and Work in

my own words Where other ideas or words have been included I have

adequately cited and listed in the reference materials The thesis has been

prepared without resorting to plagiarism. I have adhered to all principles of

academic honesty and integrity. No falsified or fabricated data have been

presented in the thesis. I understand that any violation of the above will cause

for disciplinary action by the institute, including revoking the conferred degree.

If conferred, can also provoke penal action from the sources which have not been

properly cited or from whom proper permission has not been taken

Syeda Nooma Qarneen

 ACKNOWLEDGEMENT
I whole heartediy express my profound gratitude to the pillars that holds my life.

My efforts would not have been materialized without the grace of Almighty and

the encouragement, support, and guidance of following people. It's with pleasure

and a sense of indebt that I acknowledge here the invaluable help of all those

who contributed so much to the completion of project.

I express my heartfelt thanks to the teaching and non-teaching staff of the

Department of Food and Nutrition for providing me their valuable advice and

constant encouragement.

I would also like to thank other faculty members, my family members and friends

and others who were supportive and understanding all the way. I can only offer

my deep appreciation for their willingness and patience.

I am sincerely thankful to my parents for their constant support in all my

endeavours besides being a source of inspiration and encouragement to me.

Syeda Nooma Qarneen

 CONTENT

Serial No. Name Page No.

1 List of Figures

2 List of tables

3 Abstract

4 Introduction 1

5 Literature review 18

6 Methodology 25

7 Results discussion 31

Reference 39

Appendices 45
 LIST OF FIGURES
figures Page no.
1)Pcos symptoms 2
2)female Reproductive system 3
3)Menstrual Cycle 6
4)Stages of Menstrual cycle 6
5)Ultrasound view cross sectional of 9
polycystic ovary
6)Food by Phases of Menstrual Cycle 12

LIST OF TABLES
Table Page No.
1)Socio demographic profile of subjects 31-32
2)Perception of Participants about 33-34
pcods
3)Impact of education intervention on 35
knowledge of participant
4)Impact of education intervention on 36
attitude of participants
5)Impact of education intervention in 37
practice among participants
 ABSTRACT

Polycystic Ovary Syndrome (PCOS) is an endocrine disorder that is characterized

by hyperandrogenism(clinical or biochemical), anovulation (chronic) and
polycystic ovaries. The intervention study aimed atcreating awareness among
women with PCOS, improving their nutritional knowledge, attitudes and
practices,enhancing their quality of life and physical activity through Nutrition
Education Program.Using random sampling technique, 200 respondents were
screened and 40 respondents were selected for this study. Majority of the
subjects were with 19-30 years age of the selected subjects. Various questions
were used to elicit the general information, nutritional knowledge, attitudes and
practices, information on PCOS,physical activity level and quality of life of
subjects.
Nutrition education sessions were conducted using various education materials
for a period of 3 months with a minimum of 3 sessions per subject through one
to one sessions .The statistical analysis of Pre and Post intervention study
revealed significant improvement in the mean scores of Knowledge (81.75 to
97.10) and Attitude (46.60 to 52.95),post intervention. The study helped the
subjects in improving their knowledge about the importance ofNutrition in PCOS
and instilled a positive attitude which was reflected in the scores of various
quality of lifedimensions and intensity of physical activity.
 LIST OF ABBREVIATIONS
PCOS - polycystic ovarian syndrome

PCOD - Polycystic ovarian disease

> GnRH - Gonadotropin releasing hormone

LH - Luteinizing hormone

NIH - National institute of health

GL - Glycemic load

> FFQ - Food frequency questionnaire

> IGF-1 - Insulin like growth factor -1

> DASH - Dietary approaches to stop hypertension.

> FI - Food insecurity

> PGWB - Psychological general health and wellbeing

BMI - Body mass index

> WHO - World health organization

IR - Insulin resistance

> HDL - High density lipoprotein

> OGTT - Oral glucose tolerance test

HA - Hyper androgenism

> IM - Irregular menstruation

 INTRODUCTION

Polycystic Ovary Syndrome (PCOS) is also knownas “Stein-Leventhal” syndrome

and was first describedby Stein and Leventhal in 1935. It is one of the mostprevalent
endocrine disorders that occur in womenof child bearing age and is around 5-10%
prevalent worldwide and in India.It is 52% prevalent.
1)PCOS is characterized by hyperandrogenism(clinical or biochemical), anovulation
(chronic) and polycystic ovaries.
2) Clinical features include hirsutism,irregular menstrual cycles, acne, thinning of hair
and infertility.
It is also associated with obesity, increased pregnancy related complications,
cardiovascular disease risk, diabetes mellitus, insulin resistance etc.This condition
involves hormonal imbalance which affects the follicular growth during the ovarian
cycle and leads to the formation of cysts. PCOS is one of the major causes of
infertility among women. It is emerging as one of the fastest growing health disorder
among women.The growing incidence is a result of lifestyle disorder,inappropriate
dietary habits, genetic disorders etc.

Rotterdam European Society for HumanReproduction/American Society of

Reproductive Medicine (ESHRE/ASRM) in 2003 proposed that PCOS diagnosis must
include any two of the following three criteria:

1)Oligo- and/or anovulation

2)Clinical and/or biochemical hyper androgenism
3)Polycystic ovaries on ultrasound

Other etiologies must be excluded such as androgen secreting tumors, cushing

syndrome,congenital adrenal hyperplasia, thyroid dysfunction and hyper
prolactinaemia.

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PCOS is on an increasing trend and a holistic approach is required for its
management. As per studies, the first line of intervention for women with PCOS is
lifestyle modification that includes dietary modifications, increased physical activity
and weight management along with medications which were found to be effective in
preventing the cardio-metabolic risk factors. Considering the individual’s risk profile
and treatment goals would help in managing this condition effectively.Nutrition
education is useful in order to disseminate information on healthy diet and
nutrition.To bring about a positive change in the attitude of people towards PCOS,
nutrition, healthy eating, good lifestyle pattern etc. Different methods are adopted as
nutrition education tool.Educational program that provides generalinformation about
the lifestyle modification should be included for women with PCOS to encourage
them for effective management of this condition which will also improve their studies
have shown that Educational program conducted quality of life. Many regarding
PCOS,Diet and Lifestyle intervention have improved theknowledge among women
with PCOS regarding these aspects.

Introduction to physiology of ovary:-

The ovary is an oval-shaped organ about the size of an almond. It is organized into
germ cells (ie, oocytes) and somatic cells (ie, granulosa, theca, and stromal cells) that
work together to develop dominant mature follicles that can be released through
ovulation for possible fertilization. The actions of the ovary are regulated primarily by
FSH and LH hormones produced by the Anterior Pituitary gland, as previously

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mentioned. Those hormones act as ligands to two receptor types found on somatic
cells. The actions of these cells propagate the development of the adjacent germ cells
to mature by providing an estrogen-rich environment.

An oocyte is the germ cell within the ovary that progresses through a series of
maturation steps. Primordial follicles are immature germ cells or primary follicles
arrested in prophase I of meiosis.The onset of pubescence enables the completion of
primordial follicles into primary oocytes through a process called
folliculogenesis.Primary oocytes have a single layer of granulosa cells surrounding
them. When the theca cell layer develops adjacent to the granulosa cells, the primary
follicle develops into a secondary follicle.A mature (Grafian) follicle is characterized
by the development of a liquid-filled cavity called the Antrum. Immediately prior to
ovulation, the Grafian follicle begins meiosis II and arrests at metaphase II. This
process is only completed if the oocyte is fertilized.
Somatic Cells:-Granulosa cells immediately surround the growing oocyte. They
respond to follicle-stimulating hormone (FSH) released by the anterior pituitary by
converting androgens to estrogen prior to the LH surge. The Theca cells that lie

3
outside of the granulosa cells use the androgens used by the granulosa cells. After the
LH surge, the granulosa cells undergo a receptor transition called “luteinization.”
Luteinization converts granulosa cells into cells that are receptive to the luteinizing
hormone. This process enables granulosa cells to now produce progesterone instead of
estrogen as they previously did. After ovulation, granulosa cells, in conjunction with
the theca-lutein cells, create the corpus luteum, which is primarily responsible for
progesterone.
Theca cells appear as the follicle matures and are found immediately outside the
granulosa cells. Their main function is to synthesize androgens that diffuse into the
nearby granulosa cells for conversion to estrogen. Theca cells are regulated by LH,
and these cells undergo a “luteinization” phase like the granulosa cells, where they
become “theca-lutein” cells that directly produce progesterone as part of the corpus
luteum.
Stromal cells are the connective tissue cells that create the organizational scaffolding
for the organ-specific cells. (i.e., fibroblasts, endothelial cells, epithelial cells, etc.)
Stromal cells are a major source of malignant processes, especially in the ovary. In
fact, epithelial cells are responsible for the most common type of ovarian cancer.

Development:-
The prepubertal ovary contains primordial follicles, which consist of an oocyte
surrounded by a single layer of granulosa cells. Following puberty, the anterior
pituitary begins to secrete FSH and LH in response to GnRH release from the
hypothalamus, and the dormant cells in the ovary begin to secrete steroid hormones in
response.
Organ Systems Involved:-
The hypothalamus secretes GnRH in a pulsatile fashion, which triggers FSH and LH
release from the anterior pituitary. These, in turn, act on the granulosa and theca cells
in the ovary to stimulate follicle maturation and trigger ovulation.Ovulation is a
physiologic process defined by the rupture of the dominant follicle of the ovary. This
releases an egg into the abdominal cavity. It then is taken up by the fimbriae of the
fallopian tube where it has the potential to become fertilized. The ovulation process is
regulated by fluxing gonadotropic hormone (FSH/LH) levels. Ovulation is the third
phase within the larger uterine cycle (ie, menstrual cycle). The follicular release
follows the Follicular phase (ie, dominant follicle development) and precedes the
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luteal phase (ie, maintenance of corpus luteum) that progresses to either endometrial
shedding or implantation. Follicular release occurs around 14 days prior to
menstruation in a cyclic pattern if the hypothalamic-pituitary-ovarian axis function is
well regulated.Genotypic females (XX) develop two ovaries that sit adjacent to the
uterine horns. Each ovary is anchored to the uterus at the medial pole by the utero-
ovarian ligament. The lateral ovarian pole is anchored to the pelvic sidewall by the
infundibulopelvic ligament (i.e,. suspensory ligament of the ovary), which carries the
ovarian artery and vein. Each ovary contains 1 to 2 million primordial follicles that
each contain primary oocytes (ie, eggs) that can supply that female with enough
follicles until she reaches her fourth or fifth decades of life. These primordial follicles
are arrested in prophase I of meiosis until the
At the onset of pubescence, the gonadotropic hormones began to induce the
maturation of the primordial follicle, allowing for the completion of meiosis I,
forming a secondary follicle. The secondary follicle begins meiosis II, but this phase
will not be completed unless that follicle is fertilized.With each ovulatory cycle, the
number of follicles decreases, eventually leading to the onset of Menopause or the
cessation of ovulatory function. Per each ovulation cycle, the average ovary loses
1,000 follicles to the process of selecting a dominant follicle that will be released.
This process accelerates in an age-dependent manner as well. It is also a common
thought that the right and left ovaries alternate follicular releases each month.
Ovulation is regulated by the fluctuation between the following hormones. Tight
regulation and controlled changes between the following hormones are imperative for
the development and release of an oocyte into the adnexal uterine structures.

Hormones involved in ovulation include:

1)Gonadotropin-releasing hormone (GnRH) is a tropic peptide hormone made and
secreted by the hypothalamus. It is a releasing hormone that stimulates the release of
FSH and LH from the anterior pituitary gland through variations in GnRH pulse
frequency. Low-frequency GnRH pulses are responsible for FSH secretion, whereas
high-frequency pulses are responsible for LH secretion. During the Follicular phase of
the Uterine cycle, estrogen secretion causes the Granulosa cells to autonomously
increase their own production of estrogen, contributing to elevation in estrogen serum
levels. This elevation is communicated to the hypothalamus and contributes to the

5
increase in GnRH pulse frequency, eventually stimulating the LH surge that
eventually induces the follicular rupture and release from the

Fig.Menstrual cycle

6
corpus luteum and luteinization of the granulosa cells, enabling the synthesis of
progesterone in place of estrogen. Finally, the low levels of LH following the surge
restart the FSH production by the slow-pulsation frequency of GnRH release.
Gonadotropin hormones are heterodimeric glycoproteins with alpha/beta subunits.
The alpha subunit is common to all glycoproteins, including TSH (thyroid-stimulating
hormone) and HCG (human chorionic gonadotropin hormone). [2] The relationship
between FSH and LH hormones is responsible for the process that induces follicular
development, rupture, release, and endometrial reception or shedding. Disruption in
the hormonal communication between the gonadotropin-releasing hormones,
gonadotropic hormones, and their receptors can lead to anovulation or amenorrhea,
leading to various pathologic sequelae as a consequence.
2)Follicle-Stimulating Hormone (FSH)- is a gonadotropin synthesized and
secreted from the anterior pituitary gland in response to slow-frequency pulsatile
GnRH. FSH stimulates the growth and maturation of immature oocytes into mature
(Graafian) secondary follicles before ovulation. FSH Receptors are G-protein coupled
receptors and are found in the Granulosa cells that surround developing ovarian
follicles. The granulosa cells initially produce the estrogen needed to maturate the
developing dominant follicle. After 2 days of sustained elevation of estrogen levels,
the LH surge causes luteinization of the granulosa cells into LH receptive cells. This
transition enables granulosa cells to respond to LH levels and produce progesterone.
3)Estrogen -is a steroid hormone that is responsible for the growth and regulation of
the female reproductive system and secondary sex characteristics. Estrogen is
produced by the granulosa cells of the developing follicle and exerts negative
feedback on LH production in the early part of the menstrual cycle. However, once
estrogen levels reach a critical level as oocytes mature within the ovary in preparation
for ovulation, estrogen begins to exert positive feedback on LH production, leading to
the LH surge through its effects on GnRH pulse frequency. Estrogen also has many
other effects that are important for bone health and cardiovascular health in
premenopausal patients.
4)Luteinizing Hormone (LH)- is a gonadotropin synthesized and secreted by the
anterior pituitary gland in response to high-frequency GnRH release. LH is
responsible for inducing ovulation, preparation for fertilized oocyte uterine
implantation, and the ovarian production of progesterone through stimulation of theca
cells and luteinized granulosa cells. Prior to the LH surge, LH interacts with Theca
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cells that are adjacent to granulosa cells in the ovary. These cells produce androgens,
which diffuse into the granulosa cells and convert to estrogen for follicular
development.[3] The LH surge creates the environment for follicular eruption by
increasing the activity of the proteolytic enzymes that weaken the ovarian wall,
allowing for the passage of the oocyte. After the oocyte is released, the follicular
remnants are theca and luteinized granulosa cells. Their function is now to produce
progesterone, which is the hormone responsible for maintaining the uterine
environment that can accept a fertilized embryo.
5)Progesterone- is a steroid hormone that is responsible for preparing the
endometrium for the uterine implantation of the fertilized egg and maintenance of
pregnancy. If a fertilized egg implants, the corpus luteum secretes progesterone in
early pregnancy until the placenta develops and takes over progesterone production
for the remainder of the pregnancy.

Related Testing
Home ovulation predictor kits work by measuring urine LH levels to detect the LH
surge that precedes ovulation.Mid-luteal progesterone testing can also be used to
determine in retrospect whether ovulation occurred by testing for progesterone
produced by the corpus luteum.

Clinical Significance:-
Anovulation Disorders are divided into 3 groups by the World Health Organization
1)Group I Disorders: Hypothalamic failure leading to hypogonadotropic
hypogonadism, which is responsible for 10% of anovulation cases.Examples:
Kallmann syndrome, panhypopituitarism from apoplexy, autoimmune destruction,
adenoma interference, or infections. Postpartum hemorrhage (Sheehan syndrome) or
head trauma can also cause hypothalamic failure that is irreversible or transient.
2)Group II Disorders: HPO axis dysfunction, which is responsible for 85% of
anovulatory cases.The most common cause of female infertility in the United States is
ovulatory dysfunction, in which a variety of hormonal factors interfere with the
complex sequence of hormonal events required to trigger ovulation. Problems can
occur at any point in this pathway (hypothalamus, pituitary, ovary) and can lead to
failure to ovulate. The most common cause of chronic ovulatory dysfunction in the

8
United States is polycystic ovarian syndrome, or PCOS, which interferes with
ovulation at multiple points.

Fig.Ultrasound view of Polycystic Ovary

Polycystic ovarian syndrome is considered an endocrinopathy that is the etiology for
anovulatory infertility (ie, >90% of cases). PCOS is characterized by irregular
menstrual cycles secondary to anovulatory bleeding caused by friable hyperplastic
endometrial tissue and hyperandrogenism, and it is associated with various metabolic
derangements (i.e., hyperinsulinemia).It is understood hyperandrogenism is the result
of the balance derangement between Androgen hormone levels and LH/FSH levels.
The exact mechanism for how this is caused is not entirely understood, but research
supports the thought that peripheral conversion of estrogen into androgens by adipose
tissue is one mechanism for elevating serum androgen levels and depleting estrogen.
Hyperinsulinemia secondary to insulin resistance is thought to play a role in PCOS.
During puberty, it is common for a degree of Insulin resistance to be seen resulting
from insulin-growth factor-1 (IGF-1). This process is considered largely normal if IR
is confined to glucose metabolism. In women with PCOS, IR affects multiple
systems, including the liver, resulting in decreased sex hormone-binding globulin
(SHBG) synthesis. Reduced SHBG levels contribute to the elevation of free
androgens, further deranging the hormone balance.
Immature hypothalamic-pituitary-ovarian axis

9
Anovulation that presents with irregular menstruation in adolescent females as a result
of an immature hypothalamic-pituitary-ovarian axis can be a common, expected
finding. An anovulatory pattern of menstruation can be seen during the first year after
the onset of menarche and persist till 18. The HPO axis is believed to have reached
maturation. Persistent irregularities should be further evaluated for “non-functional”
causes of inoculation.
Overview of the treatment of PCOS:-
Treatment of PCOS includes the normalisation of biochemical and clinical HA, the
optimisation of reproductive function and outcomes and the management of metabolic
morbidity and mortality. Pharmaceutical and surgical treatment of PCOS includes oral
contraceptives (oestrogen-progesterone combination therapy) to suppress LH
production and enhance SHBG production, anti-androgens (spirinolactone and
flutamide) to inhibit androgen (testosterone and 5α-DHT) binding to peripheral
androgen receptors, 5α-reductase inhibitors (finasteride) for treatment of hirsutism,
glucocorticoids to reduce adrenal androgen levels, ovulation induction agents (such as
the oestrogen receptor antagonist clomiphene citrate) and gonadotrophins for the
treatment of anovulatory infertility, laparoscopic ovarian surgery (reviewed by (258-
260)). Where the clinical features of PCOS are worsened by the presence of IR and
obesity, these are important targets for preventative and therapeutic interventions and
use of insulin sensitising agents, including the glitazones and metformin, have
increasingly been adopted as preferable pharmacological strategies both in isolation or
in combination with other pharmacological options to improve treatment response .
However, where possible use of lifestyle (dietary and/or exercise) interventions to
reduce the features of obesity, IR and hyperinsulinaemia are preferable and cost-
effective options for initial treatment strategies in PCOS compared to surgical and
pharmacological options.

Dietary management of PCOS:-

The dietary management of obesity consists of achieving and maintaining a

reduced body weight and preventing further weight gain . In obese individuals,
energy restriction and weight loss improve glycaemic control , dyslipidaemia ,
hyperinsulinaemia and IR and reduce blood pressure .Acute energy restriction
decreases human endogenous cholesterol synthesis , improves central and peripheral
10
insulin sensitivity and glycaemic control due to an enhancement of non-oxidative
glucose disposal, a reduction in insulin secretion or reduced hepatic glucose
production .
In the general population, guidelines for obesity management recommend an initial
weight loss of ~5–10% for reduction of obesity-related risk factors with long-term
goals of achieving and maintaining a reduction in weight of 10–20% and waist

11
12
circumference of < 88 cm for women (273). There are a range of principles to
consider with regards to the optimal dietary treatment of PCOS.
The success of a weight loss or weight maintenance strategy depends on a variety of
factors. The efficacy of a dietary strategy can be assessed by its ability to induce and
maintain weight loss and its effect on the composition of weight loss (fat versus lean
body mass), metabolic parameters (glucose and insulin homeostasis, lipid profile, risk
factors for cardiovascular disease and diabetes, blood pressure) and reproductive
endocrine or clinical outcomes.Furthermore, the nutritional adequacy of a particular
dietary strategy needs to be ensured, particularly where followed long-term or pre-
pregnancy, and the effect of a diet on micronutrient (vitamin and mineral) status must
be assessed .
A particular dietary strategy or composition may therefore induce either a
greater weight loss than an alternative strategy or induce a greater metabolic or
endocrine improvement than an alternative strategy with equivalent reductions in
weight. However, although weight loss can be achieved in the short-term, dietary
strategies for continued weight loss or prevention of weight regain must be
maintained long-term for successful weight maintenance. Many patients who lose
weight from dietary weight loss programmes will eventually regain the weight .A
recent meta-analysis reported approximately 15% of subjects undergoing weight loss
interventions maintain either their reduced weight or an overall reduction of 9–11 kg
at a follow-up time of up to 14 years . When weight loss maintenance is defined as
maintaining a reduction of 10% of initial body Clinically, improvements in menstrual
function and ovulation and reductions in ovarian volume and follicle number are
documented following modest weight loss .
In overweight women with PCOS, lifestyle modification techniques led to a weight
loss of 6.3 kg over 6 months and 6.8% over 48 weeks .There is as yet limited
additional data on the effect of weight loss on reducing negative reproductive
outcomes or pregnancy complications in PCOS although modest weight loss reduces
the risk of developing gestational diabetes and Clark et al reported a reduction in
miscarriage rates from 75% pre-treatment to 18% post-treatment in women with
PCOS. As both T2DM and the metabolic syndrome are more common in PCOS
than the overweight population, lifestyle modification strategies therefore also seem
appropriate in regards to their reduction of metabolic risks.

13
Altering dietary composition in the dietary management of PCOS:-
A low fat (~30% of energy, saturated fat ~10% of energy, <300 mg cholesterol daily),
moderate protein (~15%) and high carbohydrate intake (~55%), in conjunction with
moderate regular exercise is recommended by a variety of institutions for the
management of obesity and related co-morbidities . Some evidence indicates weight
is maintained more effectively and compliance is increased when this dietary pattern
is followed over longer periods of time compared to fixed energy diets. Toubro et al
assessed weight maintenance at 1 year in n=43 obese adults; 65% of the ad libitum
low fat high carbohydrate group and 40% of the fixed energy group maintained a
weight loss of >5 kg after 2 years. In a cross-sectional study assessing the dietary
patterns of 438 subjects from the National Weight Control Registry who maintained a
weight loss of 30 kg for 5.1 years, successful weight maintenance behaviours
included continued consumption of a low energy and low fat diet .However, a recent
Cochrane review of free-living subjects following low fat versus other diets reported
similar drop-out rates for most of the studied research and similar weight losses at 6
months (-5.08 versus -6.5 kg), 12 months (-2.3 versus -3.4 kg) and 18 months (+0.1
versus -2.3 kg) post-intervention, indicating a low fat diet suffers similar compliance
issues as other approaches .
Furthermore, a number of studies have demonstrated a worsening of the metabolic
profile as increases in triglycerides (due to increases in hepatic synthesis of VLDL) ,
decreases in HDL-C and increases in post-prandial insulin and glucose are
cardiovascular disease in overweight women with and without PCOS has not been
examined observed following a low fat high carbohydrate diet, particularly if weight
loss is not achieved. These are factors implicated in the pathogenesis of CVD and as
such this dietary regime may be potentially detrimental. This may also be more
pronounced in individuals with IR where the need to secrete more insulin could lead
to additional demands on the β-cell, potential β-cell exhaustion and compromised
glucose tolerance or increased hyperinsulinaemia and resultant metabolic
consequences .
Alternative approaches are thus being studied which may have more favourable
effects on the metabolic profile or may be more effective in achieving and sustaining
long-term weight loss. There has been increased community interest in dietary
strategies modifying macronutrient contribution . However, the effect of altering
dietary composition in a structured weight loss environment has been poorly studied
14
in PCOS. In this literature review a discussion of the effect of modifying diet
composition will be limited to individuals with IR, T2DM or elevated cardiovascular
risk factors as these are important features in the aetiology and presentation of PCOS.

Altering dietary glycemic index or glycemic load :-

An alternative dietary modification is altering the type of carbohydrate to produce a
lower glycemic response (low glycemic index or low GI). The GI is a classification
index of carbohydrate foods based on their effects on post-prandial blood glucose
response and the glycemic load (GL) is the product of the GI and the amount of
dietary carbohydrate .
The GL can be reduced by either decreasing the GI of the carbohydrate or by
decreasing the amount of carbohydrate with a concomitant increase in protein or fat.

15
In acute intervention studies, high GI meals decrease satiety and increase hunger and
subsequent food intake compared to low GI test meals .
In a recent 12 week study in overweight or obese adults following one of 4 isocaloric
ad libitum diets, either high or low in GI and protein, the high carbohydrate low GI
and HP high GI diets (with similar GL) had the greatest reduction in fat mass
(−4.5±0.5 kg, −4.6±0.5 kg) . Similar retention rates (82%),reductions in weight and
waist circumference and changes in body composition were observed for overweight

hyperinsulinaemic women following a 12 month weight loss maintenance program

on a HP (40% low GI carbohydrate, 30% fat, 30% protein) (6.6 kg), high
carbohydrate (55% carbohydrate, 30% fat, 15% protein, 25–30 g fibre/day) (4.4 kg) or
high fat diet (<20 grams of carbohydrate/day initially with increase up to weight
maintenance levels) (5.4 kg) .
In subjects with T2DM, coronary artery disease or hyperlipidaemia, acute weight loss
or weight maintenance low GI diets reduce daylong glucose levels, post-prandial
insulin, glycated haemoglobin and reduce triglycerides, total cholesterol or LDL-C,
plasminogen activator inhibitor 1, apolipoprotein B, FFA and increase HDL-C .

16
Summary of dietary management of obesity and overweight in PCOS:-
There are thus a range of strategies for the dietary management of overweight and
obesity in PCOS, although their comparative effectiveness on maintaining weight
loss and inducing optimal metabolic improvements is unknown. Furthermore, there
is a lack of long-term studies (>1 year) assessing the efficacy and sustainability of
different dietary and lifestyle strategies in overweight women with PCOS. The
longest follow-up time thus far is 12-15 months, with reported drop-out rates at this
time of 23–39% .Monthly follow up visits and overall weight loss of 5 kg ). In
comparison, long-term lifestyle modification trials in overweight people with IGT
demonstrate modest sustainable weight losses (5.6 kg with dropout rates of 7.5%
over 3 years) through lifestyle intervention (a low fat diet, 150 minutes exercise per
week and behaviour management strategies) which reduced the risk of developing
T2DM or the metabolic syndrome by 58% and 41% respectively .

17
 LITERATURE REVIEW
Literatures relevant to present study” Nutritional education intervention of
Polycystic Ovarian Syndrome” are cited during this chapter.
1)Study conducted by Megha M Katte et.al.2020 revealed that Dietary and lifestyle
modification play an important role in the management of PCOS. Nutrition education
intervention play critical role to bring in these changes, but very few women with
PCOS are receiving nutrition education. Knowledge related to this condition among
women is also unknown. The purpose of this study is to assess nutrition knowledge,
impart nutrition education, to study the impact and explore their relationship with
socio-economic status. Case-control study design was followed. The results reveal
significant positive correlation between nutrition knowledge at baseline of
respondents and education of parents. Respondents demonstrated poor nutrition
knowledge at baseline. There was significant increase in knowledge, attitude, practice
scores from baseline to 90th day in spite of the reduction from 45th to 90th day. This
implies that programs targeting nutrition education and behavior modification are
needed to improve the management and mitigation of PCOS-related symptoms among
women.
2)Similarv study in 2021 Conducted by R. Abobaker, Amal L.et.al. Published in
Egyptian Journal of Nursing… 1 September 2021 on the topic Effect of Educational
Program on Quality of Life among Women with Polycystic Ovarian Syndrome
revealed that to increase women's knowledge about PCOS and improve their quality
of life, health education programs should be provided to all women who access
gynecological clinics.
3) Klinika Niepłodności i Endokrynologii Rozrodu, et.al. also conducted similar study
in 2021 revealed that Polycystic ovary syndrome (PCOS) is the most common
endocrinopathy in women of reproductive age. It is manifested by hyperandrogenism,
polycystic ovaries on ultrasound, oligomenorrhoea and anovulation. PCOS patients
are more vulnerable to metabolic disorders: insulin resistance, obesity, endothelium
dysfunction, atherosclerosis, and activation of proinflammatory factors. This
association shows that PCOS might be an ovarian manifestation of a metabolic
syndrome. Insulin resistance is also strongly correlated with reproductive failure.
Approximately 100 factors, secreted in adipose tissue, are responsible for its
regulation. Adipocytokines have been found to play an important role in regulating
insulin sensitivity. Abnormal levels of adipokines are detected in patients with insulin
18
resistance. Counseling PCOS patients about the possibility of developing metabolic
syndrome, diabetes mellitus, and cardiovascular diseases should be a standard of
care.weight loss Diet and exercise are helpful in controlling these conditions.
4)Nepal J Epidemiol. 2021 Sep; Published online 2021 Sep 30. Conducted study
among adolescent girls.Study revealed that Polycystic ovary syndrome (PCOS) is a
common endocrine disorder in the progenitive age group and the leading cause of
infertility. The worldwide prevalence of PCOS in women varies between 2.2% to
26%. Due to limited literature on burden of PCOS among adolescent girls, its
significance is still unfathomed as a research is few and far between in the present
time. We conducted Systematic review and metanalysis to estimate the pooled
prevalence of PCOS among Indian adolescent girls (14-19 years).
5)PLoS One. 2021; 16(3): e0247486. Published online 2021 Mar 10. Conducted study
on Impact of polycystic ovary syndrome on quality of life of women in correlation to
age, basal metabolic index, education and marriage.Study outcomes as Polycystic
ovary syndrome (PCOS) is the major endocrine related disorder in young age women.
Physical appearance, menstrual irregularity as well as infertility are considered as a
sole cause of mental distress affecting health-related quality of life (HRQOL). This
prospective case-control study was conducted among 100 PCOS and 200 healthy
control cases attending tertiary care set up of AIIMS, Patna during year 2017 and
2018. Pre-validated questionnaires like Short Form Health survey-36 were used for
evaluating impact of PCOS in women. Multivariate analysis was applied for statistical
analysis. In PCOS cases, socioeconomic status was comparable in comparison to
healthy control. But, PCOS cases showed significantly decreased HRQOL. The
higher age of menarche, irregular/delayed menstrual history, absence of child, were
significantly altered in PCOS cases than control. Number of child, frequency of
pregnancy, and miscarriage were also observed higher in PCOS cases. Furthermore,
in various category of age, BMI, educational status and marital status, significant
differences were observed in the different domain of SF-36 between PCOS and
healthy control. Altogether, increased BMI, menstrual irregularities, educational
status and marital status play a major role in altering HRQOL in PCOS cases and
psychological care must be given during patient care.
6)Study conducted about The Knowledge and Awareness on Polycystic Ovarian
Syndrome among Lady Health Visitors in Public Health Nursing School Lahore , by
Saba Kiran et.al. in 2020 revealed that adolescent through post-menopausal age, the
19
clinical characteristics of this illness may alter . According to ultrasound examination,
up to 22% of women in the general population have polycystic ovaries, making PCOS
one of the most frequent endocrine disorders affecting women of reproductive age .
In general, PCOS prevalence estimates are extremely diverse and range from 2.2% to
26%. According to the World Health Organization (WHO), 116 million (3.4%)
women worldwide had PCOS in 2012 .Another study found that the estimated
prevalence of PCOS was an exceptionally high 53.7%. 40% of women with PCOS
experience infertility as the most common reason of anovulatory behaviour . PCOS
affects 90% to 95% of anovulatory women who visit infertility clinics. Diet and
exercise play important role managing pcos.
7)On the topic Polycystic Ovary Syndrome: A Literature Review With a Focus on
Diagnosis, Pathophysiology, and Management By Shrutika V. Waghmare et.al
revealed that In females with polycystic ovarian syndrome (PCOS), the most
prevalent endocrine condition is chronic anovulation and hyperandrogenism. Patients
will experience different androgenic symptoms, such as hirsutism, acne, and/or
baldness. Patients who appear with these troubling symptoms need to receive
appropriate care. The review emphasizes the role it plays in the management of
various cases.
8)Study published in SYSTEMATIC REVIEW article Front. Endocrinol., 02
December 2022 Sec. revealed that Effect of educational program on the level of
knowledge regarding polycystic ovarian syndrome among adolescent girls. The aim
of the study is to evaluate the effect of educational program on the level of knowledge
regarding PCOS among adolescent girls. A systematic review of lived experiences of
people with polycystic ovary syndrome highlights the need for holistic care and co-
creation of educational resources.
9)Similar study on the topic Impact of Educational Intervention on the Knowledge of
Polycystic Ovarian Syndrome among Lady Health Visitors conducted by Shweta
KIRAN et.al.1-Clinical Nursinginstructor Al Haramain Institute of Health Sciences
2,3-Nursing Instructor Aligarh College of Nursing and Allied Health Sciences 4-Sr.
Nursing Instructor Aligarh College of Nursing and Allied Health Sciences revealed
that there is a positive impact of nutritional education among women in reproductive
age in managing prolonged pcos condition and symptoms can be reversed.
10) A Study conducted on the topic Effect of Educational Programme on Lifestyle
among Paramedical Students with Polycystic Ovarian Syndrome in 2022 by Zeinab
20
R. AL Kurdi et. al. Aimed To evaluate the effect of educational program on lifestyle
for paramedical students with polycystic ovarian syndrome. The study conducted at
two government colleges in Jordan. Study Design: A Quasi- experimental (pre-test &
post-test) design was utilized in this study. by Identification of students with PCOS
tool, Assessment of lifestyle habits tool, POCS structured interviewing questionnaire
tool, Follow up sheet, and Psychological assessment tool. The present study findings
revealed that a highly significant difference regarding the student's knowledge about
the PCOS as compared pre, post, and follow-up program results. Also, there was a
significant improvement in the student's lifestyle habits after applying to the
educational program compared to befoe applying them.
11)In Health Science ReportsVolume 3, Issue 4 2020 RESEARCH ARTICLE
published similar study conducted by , Jain Vanitha, Fabiola M. Dhanaraj, Prema
Sekar, Anitha Rajendra Babu et.al. in womens with pcos revealed about the Impact of
yoga and exercises on polycystic ovarian syndrome risk among adolescent schoolgirls
in South India Valarmathi SelvarajFirst published: 04 December 2020.To identify the
adolescent school girls with risk for polycystic ovarian syndrome (PCOS), assess their
risk status, and evaluate the impact of lifestyle modifications on PCOS risk reduction
12)Hemlata Gajbe Lecturer et.al. published study in Article Revised on 24/06/2022
Article Accepted on 14/07/2022 ,revealed that “Learning is the beginning of
wealth,Searching and learning is where the miracle process all begins”.Polycystic
Ovarian Disease was first described by Irving stein and Micheal Leventhal as a Triad
of ‘’Amenorrhea‟, „Obesity‟, and „Hirsutism‟ in 1935 when they observed the
relation between obesity and reproductive disorders. It is hence also known as
the‘’Stein- Leventhal Syndrome‟ or „Hyper androgenic An ovulation‟ and is the most
common endocrine ovarian disorder affecting approximately 2-8% women of
reproductive age. Now a day‟s, it is also referred to as the „Syndrome O‟ i.e. over
nourishment, overproduction of insulin, ovarian confusion and ovulatory disruption.
Polycystic Ovary Syndrome is a set of symptoms due to elevated androgens in
women. Which can be controlled by yoga and low fat diet.

13) Ms. Khushbu Barar in2020 conducted a study on the topic Knowledge regarding
Poly Cystic Ovarian Syndrome (PCOS) among the Teenage Girls and its nutritional
management revealed that in Adolescents ‘challenge is that Polycystic ovarian
Syndrome is a systemic, complex disorder that needs to be actively managed by them
21
for the rest of their life. Using selected structured questionnaire in schools at Mohali,
researcher assessed the level of knowledge of adolescent girls regarding Polycystic
Ovarian Syndrome and its management .Study revealed that there is very poor
education in adolescent girls regarding this.
14) Lathia, Tejal et.al. conducted and published study as A Practitioner’s Toolkit for
Polycystic Ovary Syndrome Counselling published in Indian Journal of
Endocrinology and Metabolism Jan–Feb 2022. Revealed that educational programme
is very effective in counseling of pcos patients dietary modification must be
included,as it plays a vital role in mangigng hormone levels nad reversal of
symptoms.
15)A study conducted on the topic Effect of educational program on the level of
knowledge regarding polycystic ovarian syndrome among adolescent girls By H.
Mohamed et.al.,revised in 2021 in Education Journal of Nursing Education and
Practice TLDR revealed that Educational program is effective in improving the
knowledge of adolescent girls regarding polycystic ovarian syndrome and Nursing
curriculum should be updated to include comprehensive information about PCOS to
improve the awareness of other women .Structured teaching programme on
knowledge about polycystic ovarian syndrome among adolescent girls.
16)Educational Program conducted on the topic Effect on Knowledge and Lifestyles
among Paramedical Students with Polycystic Ovarian Syndrome (PCOS) By Zeinab
R. et.al.Medicine, Education 2021 ,It is revealed that a highly significant
improvement in knowledge and lifestyle among the studied sample pre intervention
compared to post and follow-up intervention P < 0.01.
17)A study conducted on knowledge and awareness about nutritional
management on polycystic ovarian syndrome among nursing students in a tertiary
centre in South India byR. SasikalaDeepa ShanmughamJ et.al.The New Indian
Journal of OBGYN 2021..revealed that Even though the nursing students had
knowledge regarding the risk factors associated with PCOS, their awareness about the
complications of PCOS and nutritional management is significantly less.
18) R. JaberAmerah et.al. conducted study on Knowledge and attitudes towards
polycystic ovary syndrome nutritional management by African journal of
reproductive health 2022 revealed that The level of education and occupation were
found to have a positive association with knowledge and attitude towards the disease,

22
while marital status and age were only found to be the most preferred source of
knowledge for further information about nutritional management of PCOS.
19)As study conducted on The Influence of Video-Based Health Education in
Modifying Early Screening Efforts for Polycystic Ovary Syndrome (PCOS) By N.
ArianiN. et.al. Education Asian Journal of Health Research 2022 revealed that There
was a significant change between the provision of health promotion in the form of
video-based learning form on young women’s knowledge, attitudes and behaviors
related to the PCOS early screening.
20) M. AliOmayma M. Mahmoud conducted study similar to this in 2019 on
POLYCYSTIC OVARIAN SYNDROME KNOWLEDGE AND AWARENESS OF
NON MEDICAL UNDERGRADUATE STUDENTS revealed that , level of
knowledge and awearness of PCOS of non medical famle students was poor and its
assessment is needed to be a part of care monitoring and improvement courses.

Aim and Objectives

1. To screen and select the subjects with PCOS using standardized PCOS screening
questionnaire.
2. To assess the Nutritional Knowledge, Attitudes,Practices, Quality of Life and
Physical activity of the screened subjects using validated questionnaires pre and post
intervention.
3. To develop nutrition education materials for the management of PCOS and to
conduct an intervention study on the experimental group using the developed
education materials.

JUSTIFICATION

Polycystic ovarian syndrome (PCOS) is a combination of metabolic, endocrine and

reproductive disorders .Approximately 5–12% of the female population worldwide
have been diagnosed with PCOS . Irving
Stein and Michael Leventhal described PCOS in 1935 as enlarged polycystic ovaries
that were often accompanied by amenorrhea and hirsutism . Te spectrum of PCOS
symptoms were identifed in the past two decades. Classic presentations of PCOS
include clinical or biochemical signs of increased serum androgen levels; menstrual
23
abnormality in the form of amenorrhea, oligomenorrhea, or anovulation, infertility,
hirsutism, as well as overweight or obesity. Women with PCOS are prone to
cardiovascular disease, obstructive sleep apnea, hyper insulinemia and impaired
glucose metabolism; and metabolic syndrome. PCOS has a dramatic impacts on
women, especially due to infertility, cardiometabolic disease, and their psychological
complications .A structured education module will help patients to have a better
understanding of their condition and proceed with lifestyle modifcation . Te most
appropriate means of generic and specifc interventions to support attitude and
behaviour change at population and community levels .
As little as 5% to 14% weight loss is linked to improvements in CVD factors,
reducing abdominal fat, blood glucose, blood lipids, IR, serum androgens and
increasing menstrual cyclicity, ovulation, and fertility [11]. PCOS in pregnancy can
increase the risk of maternal complications, including pregnancy-induced
hypertension (PIH), preeclampsia (PE), gestational diabetes mellitus (GDM), preterm
birth (PTB), and cesarean section, as well as fetal complications, including neonatal
morbidity, prematurity, fetal growth restriction (FGR), and neonatal complications,
including large for gestational age (LGA) and small for gestational age (SGA),
Neonatal Intensive Care Unit (NICU) admission . Therefore, aside from its cost-
efectiveness, lifestyle management is recommended to be implemented as the frst line
in management of metabolic syndrome and that the intervention should consist of
physician and non-physician health professionals, which may include dietician, a
professional in health education or behavioural psychology . Our study aimed to
evaluate the changes in knowledge, attitude and practise of nutrition and physical
activity as well as the eating attitude among women with PCOS when given
intervention in form of an educational module.

24
 METHODOLOGY & MATERIAL

The study entitled“Nutrional education intervention of Polycystic

Ovarian Syndrome” was carried out with the protocol which includes various
methods and materials. The detail of materials, methods and techniques were adopted
during the study are collaborated in this chapter.

1. Design of the study

2. Selection of sample
i. Selection of District
ii. Selection of Area
iii. Selection of Respondents

3. Collection of Data
i. Data collection from respondents regarding
a) General profile and personal data
b) Nutritional status of pregnant women
i. 24 hours dietary recall
ii. Anthropometric measurement
iii. Clinical Signs and Symptoms
iv. Biochemical Profile
v. General Awareness

4. Development of Nutrition Education Materials

i. Powerpoint presentation
ii. brochure
iii. Chart

5. Nutrition Education and its impact assessment

i. Pre-exposure knowledge test
ii. Exposure to nutrition education materials
Nutrition education through ppt, brochure and chart.
iii. Post-exposure knowledge test
iv. Score allotment
a) Comparison of pre and post exposure score for impact analysis
b) Assessment of gain in knowledge

25
6. Data analysis and application of statistical tests

LOCALE OF STUDY:-
The study is conducted at Life care Clinic,Nanded under the supervision of
gyanacologist in the duration of 3 months.
Inclusion criteria:
Pre-University, Undergraduate and Post Graduate students and women aged between
19-30 years of age.Confirmed cases of PCOS were selected basedon Rotterdam
criteria which requires the presence of anytwo of the following:
1)Oligo/anovulation
2)Clinical or biochemical signs of hyperandrogenism
3)Polycystic Ovaries on Ultrasound
4)Subjects willing to be a part of the study.
Exclusion criteria:
1)Subjects beyond the required age group.
2)Individuals with congenital adrenal hyperplasia,androgen secreting tumors, Cushing
syndrome, thyroiddysfunction and hyper prolactinaemia as mentioned inthe
Rotterdam criteria of PCOS diagnosis.
3) Subjects who are not willing to be a part of the study.
Sample size and Selection of subjects:
Subjects were selected using random sampling technique. The
sample size was 40. Average age of the selected subjects was24.5 years.
Screening questionnaire was presented to 200 subjects along with the pamphlets
which were developed as a part of Nutrition Education material to give general
information about PCOS. Out of 200 subjects, responses were recorded from
subjects.Based on the inclusion criteria, 50 subjects could be considered for the study.
Out of 50, few candidates did not respond and few did not wish to participate in
thestudy and therefore 40 respondents were selected to undertake the
study.Ultrasounds were not carried out on women who did not present with clinical
symptoms of PCOS, as was also the case in an Asian community study of PCOS
prevalence. There may have been some women in this group who had
hyperandrogenism and polycystic ovaries but literature suggests this is likely to be
less than 1 per cent of those with PCOS (Kumarapeli et al., 2008).
26
Research Design:-
Evaluation Tools
1)SCREENING QUESTIONNAIRE
A pre-developed screening questionnaire was used to screen subjects and identify
women with PCOS. The questions were based on the awareness, diagnosis and
treatment taken for PCOS, regularity of menstrual cycles and other related
information, presence of symptoms of PCOS, weight gain and weight fluctuations,
family history of metabolic syndrome, presence of any psychological conditions,
frequency and intensity of physical activity, eating and sleep patterns.
2)KAP QUESTIONNAIRE
Validated KAP questionnaire was used for the present study in order to assess the
knowledge, attitude and practices of subjects having PCOS pertaining to nutrition.
The questionnaire also included certain questions eliciting information about social
and economic background.
POLYCYSTIC OVARY SYNDROME – QUALITY OF LIFE QUESTIONNAIRE
The PCOS Health-related ‘Quality of Life’questionnaire is a validated and reliable
questionnaire developed by the researcher to analyze the health-related concerns of
women with PCOS and its effect on their quality of life. The questionnaire involves
questions pertaining to different aspects such as psychosocial and emotional status of
the individual, fertility related concern of the individual, sexual
function/satisfaction,obesity and menstrual disorders related concern,hirsutism
disorders related concern and the individual scoping with the condition.
3)Powerpoint presentation briefing about the condition.

Nutritional counseling:-
The nutritional counseling was done using developed educational materials for PCOS
subjects that included balanced diet, food groups, importance of nutrition in PCOS,
management of PCOS symptoms through nutrition. The subjects were given
counseling on individual basis weekly for a month minimum of 1 hours. This was
followed by assessment to understand the impact. Counseling was given at the time of
diagnosis, during their follow-up visits and by personal consultation.

27
NUTRITION EDUCATION MATERIAL:-
Nutrition Education Materials that were used for effective communication of the
subject matter during Nutrition Education sessions included Brochure related to
nutrional assessment in women.

Summary of the Intervention programme:

Duration: Nutrition education sessions were conducted for a period of 3 months .
Pre-Intervention: At the beginning of the session,the subjects were instructed to for
a verbal consent. Prior to the Nutrition Education session, the subjects were
instructed to fill the questionnaires including Validated KAP questionnaire, Quality of
Life.

Intervention Tools used:

Powerpoint presentation, Brochure

Topics covered:
Awareness on PCOS and basics of Nutrition.Importance of diet, physical activity and
behavior modification for the overall health improvement.

Post-Intervention:
After the completion of the education sessions, the overall improvement in the
subjects’ dietary habits, physical activity and psycho emotional health were analyzed
using Validated KAP questionnaire.
The screening questionnaire helped in eliciting thebasic information and signs and
symptoms, diagnosis,co-morbidities, medication consumption, diet and eatingpattern,
physical activity level and emotional well-beingof the subjects
Analysis of 200 respondents revealed that:
79% of the screened subjects were interested in knowing about nutritional
management of PCOS and 39% were anticipating few nutrition education sessions.
56 respondents were found positive for PCOS.
The KAP questionnaire helped in acquiring the information regarding Knowledge,
Attitude and Practices of the selected subjects pertaining to Nutrition and PCOS.
The KAP (Knowledge, Attitude and Practices) interview schedule was administered
28
to the respondents at the baseline. After this, using the developed tools education
intervention was done. Impact study was conducted using the same KAP
questionnaire on 45th day and on the 90th day to check the retention of knowledge,
change in attitude and continuation of practices among the subjects (Intervention was
done from 45th to 90th day). The per cent increase in KAP scores was calculated as
follows:
The formula used is:-

1. Collection of Data
General profile: This section includes the respondent’s name, age, family type,
family size, educational status, occupation status, occupation type and family annual
income.
Age- The age of the respondents were categorized in different groups i.e. 19-23
years, 24-27 years and 27-30 years.
Type of family- The selected women were categorized according to their family type
into two groups; nuclear and joint families. Those who were living alone, with spouse
and unmarried children were considered as nuclear family and those who were living
with their married children were classified as joint family.
Educational status- The educational status of each selected respondent was
categorized as post-graduate, graduate, intermediate, high school, primary education
and illiterate.
Occupation- The selected respondents were grouped according to their occupation as
profession, shop owner/ clerk/ farmer, skilled worker, unskilled worker and
unemployed (housewife).
Income- On the basis of family monthly income (Rs. Per month), respondents were

29
categorized according to Modified Kuppuswamy scale (Singh et al., 2017) into
following classes:-
I. >41430
II. 20715-41429
III. 15536-20714
IV. 10357-15535
V. 6214-10356
VI. 1092-6213
VII. <2091
Related tests:-
The attenders were evaluated through Rotterderm Criteria,and ultra sound scanning if
needed.

30
 RESULT AND DISCUSSION
Revised Kuppuswamy’s socio-economic scale was used to arrive at socio-economic
class of the respondents. Most of the respondents belonged to lower middle class (46%
). Statistical analyses showed that there was no significant difference between the
groups with respect to socio-economic class though there was a significant difference
with respect to monthly family income. This is mainly because Kuppuswamy’s scale
considers three factors like education, occupation of the family head and monthly
income of the family to arrive at socio-economic class. Earlier studies have reported
that the prevalence of PCOS was observed more in higher socio-economic group
(Malik et al., 2014) [7] which is in contrary to the finding of our study where the PCOS
subjects belonged mostly to lower middle class. The reason might be, in higher socio-
economic group due to increased affordability to medical facilities PCOS diagnosis is
more compared to lower socio-economic status. It is evident from the current findings
that PCOS is prevalent in all socio- economic classes of the society .
Three groups were prepared according to 19-22 year,23-27 years,27-30 years just for
help in collecting data.

Variables Categories Group 1 Group 2 Group 3

No. % No. % No. % χ2

Family type Nuclear 42 84.00 44 88.00 40 80.00

1.19NS
Joint 08 16.00 06 12.00 10 20.00
NS
Small 17 34.00 21 42.00 19 38.00 2.06
Family size
Medium 22 44.00 23 46.00 21 42.00

Large 11 22.00 6 12.00 10 20.00

Profession 3 6.00 5 10.00 4 8.00

Semi-profession 6 12.00 6 12.00 7 14.00

Occupation 11.11NS
Clerical, Shop-owner 6 12.00 6 12.00 9 18.00

Skilled worker 19 38.00 7 14.00 16 32.00

31
 Semi-skilled worker 9 18.00 15 30.00 11 22.00

Unskilled worker 7 14.00 11 22.00 3 6.00

>41430 3 6.00 5 10.00 4 8.00

Family income
20715-41429 11 22.00 9 18.00 16 32.00
(Rs.) 11.28*
15536-20714 19 38.00 14 28.00 23 46.00

10357-15535 9 18.00 17 34.00 5 10.00

6214-10356 8 16.00 5 10.00 2 4.00

Upper 3 6.00 5 10.00 4 8.00

Socio-economic 5.86NS
Upper middle 14 28.00 9 18.00 19 38.00
class
Lower middle 23 46.00 23 46.00 22 44.00

Upper lower 10 20.00 13 26.00 5 10.00

Table 1 :Sociodemographic profile of subjects

32
 Group 1 Group 2 Group 3
Variables Category
No. % No. % No. %
Familiar of Yes 18 36.00 17 34.00 12 24.00
PCOS No 17 34.00 13 26.00 20 40.00
condition Not sure 15 30.00 20 40.00 18 36.00
3 24 48.00 32 64.00 0 0.00
Time since
6 12 24.00 8 16.00 0 0.00
diagnosis
12 8 16.00 5 10.00 0 0.00
(duration in
>12 6 12.00 5 10.00 0 0.00
months)
Not applicable 0 0.00 0 0.00 50 100.00
Irregular/ unpredictable
42 84.00 27 54.00 0 0.00
menstruation
Hair growth 12 24.00 5 10.00 0 0.00
Worry/concer Weight gain 32 64.00 19 38.00 0 0.00
n on Acne 15 30.00 14 28.00 0 0.00
diagnosis@ Difficulty conceiving 42 84.00 35 70.00 0 0.00
Not applicable 0 0.00 0 0.00 50 100.00
Print media 12 24.00 5 10.00 7 14.00
Radio 3 6.00 0 0.00 1 2.00
Television 6 12.00 6 12.00 5 10.00
Internet 8 16.00 13 26.00 5 10.00
Source of
Gynaecologist 15 30.00 20 40.00 6 12.00
awareness
Other health professional 3 6.00 4 8.00 21 42.00
Friends and family 3 6.00 2 4.00 5 10.00
Allopathy 14 28.00 10 20.00 0 0.00
Ayurveda 7 14.00 0 0.00 0 0.00
Homeopathy 6 12.00 2 4.00 0 0.00
Treatment Diet 3 6.00 4 8.00 0 0.00
@
undergone Exercise 6 12.00 13 26.00 0 0.00
None 28 56.00 0 0.00 50 100.00
Improvement Yes 8 16.00 6 12.00 0 0.00

33
 on therapy No 14 28.00 8 16.00 0 0.00
Not applicable 0 0.00 0 0.00 50 100.00
Diet + Yes 10 20.00 18 36.00 20 40.00
Exercise can No 5 10.00 12 24.00 9 18.00
control PCOS Not sure 35 70.00 20 40.00 21 42.00

Table 2: perception of subjects about PCODS

PCOS related information as perceived by the subjects was recorded and is shown in
Table 2. multiple responses. The results show that, the subjects familiar of PCOS on
diagnosis and were unaware for the condition on diagnosis, the biggest concerns
expressed were, unpredictable menstruation, difficulty conceiving and weight gain
(84%, 85% and 64% respectively). Source of awareness about PCOS condition was
found be gynaecologist among women with PCOS. Among the control group, it was
other health professionals (42%). Other than these, internet and television were found
to be the source of information. Forty-four per cent of the women were on treatment
for PCOS and chose allopathy. 28 per cent of women said there was no improvement
on therapy. some said that they are unsure whether diet and exercise can control
PCOS. Whereas, 40 per cent believed that diet and exercise can control PCOS.

34
 Impact of education intervention on KAP

Knowledge score
Group Test
Mean ± SD Mean (%) SD (%)
Baseline 6.02 ± 2.97 40.13 19.82
45th day 10.78 ± 2.45 71.87 16.35
Enhancement 4.76 ± 1.60 31.73 10.65
Group 1
90th day 9.42 ± 2.30 62.80 15.36
Reduction 1.36 ± 0.88 9.07 5.83
Baseline 7.04 ± 2.89 46.93 19.24
45th day 10.82 ± 2.58 72.13 17.23
Enhancement 3.78 ± 1.60 25.20 10.72
Group 2
90th day 9.32 ± 2.43 62.13 16.19
Reduction 1.5 ± 1.11 10.00 7.41
Baseline 5.48 ± 2.34 36.53 15.61
45th day 10.50 ± 1.84 70.00 12.29
Enhancement 5.02 ± 1.80 33.47 12.01
Group 3
90th day 8.94 ± 1.78 59.60 11.85
Reduction 1.56 ± 0.97 10.40 6.48

Table 3: Impact of education intervention on knowledge of PCOS among the subjects

35
 Attitude score
Group Test
Mean ± SD Mean (%) SD (%)
Baseline 42.96 ± 9.48 57.28 12.64
45th day 60.68 ± 6.85 80.90 9.13
Enhancement 17.72 ± 5.92 23.63 7.90
CP (n = 50)
90th day 56.48 ± 7.22 75.31 9.63
Reduction 4.2 ± 2.18 5.60 2.90
Baseline 48.28 ± 9.21 64.37 12.27
45th day 63.70 ± 8.19 84.93 10.92
Enhancement 15.42 ± 6.26 20.56 8.35
NP (n = 50)
90th day 58.62 ± 8.41 78.16 11.22
Reduction 5.08 ± 2.95 6.77 3.94
Baseline 37.76 ± 9.22 50.35 12.29
45th day 55.92 ± 7.18 74.56 9.57
Enhancement 18.16 ± 6.78 24.21 9.04
CN (n = 50)
90th day 49.88 ± 8.51 66.51 11.34
Reduction 6.04 ± 3.05 8.05 4.08

Table 4: Impact of education intervention on attitude towards PCOS among the

respondents

36
 Practice score
Group Test
Mean ± SD Mean (%) SD (%)
Baseline 3.58 ± 1.26 35.80 12.63
45th day 7.82 ± 0.83 78.20 8.25
Enhancement 4.24 ± 1.44 42.40 14.36
Group 1
90th day 7.56 ± 0.93 75.60 9.29
Reduction 0.26 ± 0.66 2.60 6.64
Baseline 3.26 ± 1.02 32.60 10.26
45th day 8.14 ± 0.70 81.40 7.00
Enhancement 4.88 ± 1.08 48.80 10.81
Group 2
90th day 7.92 ± 0.90 79.20 8.99
Reduction 0.22 ± 0.58 2.20 5.82
Baseline 6.24 ± 1.24 62.40 12.38
45th day 8.52 ± 0.54 85.20 5.44
Enhancement 2.28 ± 1.21 22.80 12.13
Group 3
90th day 8.36 ± 0.69 83.60 6.93
Reduction 0.16 ± 0.37 1.60 3.70

Table 5: Impact of education intervention on practices to avoid/combat PCOS among

the study population

Table 3, 4 and 5 indicate the knowledge scores at baseline, 45th day and 90th day.
Enhancement of scores on 45th day and reduction of scores on 90th day were
calculated. The tables show that there was significant increase in KAP scores from
baseline to 45th day and the reduction of KAP scores from 45th day to 90th day was
also significant. In spite of the reduction in scores from 45th day to 90th day, there
were improvements in KAP scores from baseline to 90th day. And the results were
found to be statistically significant at 1 per cent level.

37
 Conclusion

There is lack of awareness and women seem to look at uterus health only from the
fertility point of view and are negligent about the treatment and preventive measure to
be practiced. Hesitation among the public to talk about menstruation still prevails.
Hence, there is need for educating the women about uterus health to lead a healthy life
and to encourage them to adopt healthy lifestyle in order to lead a better life. There is
need for educating at young age starting from teenagers to change the perception of
the society. This can be made a part of their curriculum.
From the study it can be concluded that there was a significant improvement in
knowledge and attitudes among subjects pertaining to Nutrition and PCOS. There was
also an improvement in the various dimensions of quality of life and the intensity of
physical activity level of the subjects.

38
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 APPENDIX A

QUESTIONNARE
1. Name of the respondent:

2. Age:

3. Village/address

4. Religion: (a) Hindu (b) Muslim (c) Sikha (d) Christian (e) other

5. Type of family: (a) Nuclear (b) Joint

6. Number of family members:

7. Educational status: (a) Below 8th standard (b) Below 12th standard (c)
Graduate (d) Post graduate (e) Illiterate

8. Occupation:

9. Husband’s occupation:

10. Total family Income in (Rs./ month):

11. Pregnancy status:

a) Is it your first pregnancy: (a) yes (b) no

b) If no how many children do you have?

c) Procedure of delivery: (a) Normal (b) LSCS

d) Anymiscarriages: a) yes (b) no

45
12. FAMILY HISTORY
(a) Obesity
(b) Hypertension
(c) Diabetes

13. PAST MEDICAL PROBLEMS

(a) Diabetes
(b) High blood pressure
(c) Heart disease
(d) Thyroid disorder
(e) Kidney or bladder disease
(f) Infertility

14. LIFESTYLE:
1. Time of woke up in the morning:

(a) Early morning (b) After 7am (c) After 9 am (d) After 11am

2. Time of sleeping in the night:

(a) Before 8pm (b) Before 9pm (c) Before 11pm (d) Late night

3. Do you exercise?: (a) yes (b) no

4. And duration of exercise (a) Less than 1 hour (b) More than 1 hour

5. Have you ever smoked? (a) Yes (b) No (c) Current smoker (d) Quit

6. Do you consume alcohol? (a) Yes (b) No

46
15. DIETARY ASSESSMENT:
1. Food habit : (a)Vegetarian (b) Non-vegetarian(c) Ovo-vegetarian
2. Dietary pattern:
(a) Breakfast +lunch+dinner
(b) Breakfast+lunch+evening tea+dinner
(c) Breakfast+midmorning+lunch+evening tea+dinner+bed time
3. How is your appetite? (a) Good (b) fair (c) poor
4. Do you skip any meal? (a)YES (b) NO
16. ANTHROPOMETRIC SURVEY:
(a) Height
(b) Weight
(c) Weight gain during pregnancy
(d) Body Mass Index (BMI)
17. 24 HOUR DIETARY RECALL

Total consume Raw ingredients used

Type of
quantity
Meal preparation
Ingredients Quantity (g.)

Breakfast

Lunch

Dinner

Other (Tea, biscuit,

snacks etc.)

47
 18. FOOD CONSUMPTION FREQUENCY

4-6 2-4 1-2

Food groups Daily Occasionally Never
times/week times/week time/week

Cereals

Pulses

Milk/milkproducts

GLV

Root and tubers

Fruits

Meat/poultry

Fats and oil

Sugar and
Jaggery

19. CLINICAL SURVEY

A. General appearance
(a) Good (b) Fair (c) Poor (d) Very good
B. Eyes colour
(a) Normal (b) Pale
C. Nails colour

48
(a) Normal (b) Pale
D. Gums
(a) Normal (b) Bleeding
E. Appetite
(a) Normal (b) Anorexia
F. Fatigue
(a) Present (b) Absent
G. Dermal lesion
(a) Present (b) Absent
H. Skin colour
(a) Normal (b) Pale
I. Behavioural implication
(a) Normal (b) Irritable
20. BIOCHEMICAL ESTIMATION
(a) Haemoglobin level (g/dl blood)
KAP QUESTIONNARE:-
Clinical signs of PCOS among the subjects:-
Number Percentage
Yes
Subjects diagnosed with PCOS
No
Total
Number Percentage
Specific test done by the subjects Yes
for the diagnosis of PCOS No
Total
Number Percentage
Yes
Excess of hair growth on face
No
Total
Number Percentage
Presence of coarse hair growth at Yes
3 or more sites No
Total

49
 Undergone Notice of irregular Menstrual cycle
tests to
confirm A year
After more
PCOS after Two years
No irregularity than two
attaining later
years
puberty

Yes

No

Yes
Occurrence of regular
No
menstruation
Sometimes
Total

Less than 25 days

Frequency of
Every 25th day
occurrence of menstrual
More than 30 days
cycle
Variable days
Total

Time of noticing No irregularity

irregular menstrual
A year after attaining puberty
cycle

Two years later

50
 After more than two years

Total

Observation during
menstruation

51
APPENDIX B

52
53
54
55
Balanced Diet for PCOS

56
57
58
59